From today on, the author will write an article about the day’s reading experience every day and share it with everyone. I don’t dare to say that I have a high position, but I just want to do something ceremonial and force myself to read every day. If you can see it I am very lucky to have learned something from it.
In the past few days, I have been reading a book called "Black Box Thinking" written by the British writer Matthew Said. The author turned out to be a British table tennis star. After retiring, he was admitted to Oxford University through self-study. His experience is somewhat similar to mine. I was also an athlete in judo, so my results were naturally not comparable to Matthew's. After I retired, I was also studying on my own, hoping to get into a good school like him.
Without further ado, let’s introduce this book first. The so-called “black box” refers to the special electronic recording device on the aircraft. There are generally two, one records various data during the flight. Another records a transcript of voice conversations in the cockpit. Black boxes are usually brightly colored such as red or orange to facilitate the search after an aircraft accident. Its shell has a very thick steel plate and many thermal insulation, impact and compression protection materials, and is usually installed in the safest part of the aircraft. The recording medium is a static storage recorder that can withstand large impacts. Very difficult to damage in a plane crash. "Black box thinking" refers to the inspiration obtained from the black box of the aviation industry, and how we should face the inevitable mistakes and failures in every life.
The book begins with two stories. The first story tells about a housewife with a happy family and a happy marriage who needs a minor operation because she suffers from sinusitis. The doctors who performed the surgery were all experienced doctors, and this kind of minor surgery should be easy for them. But during the anesthesia before surgery, the anesthesiologist encountered a problem. A tube that was supposed to be inserted into the patient's respiratory tract could not be inserted. The patient went into shock, and the anesthesiologist and attending physician desperately tried to lower the tube into the airway, ignoring another method designed to deal with this situation: tracheostomy. After trying repeatedly for nearly 20 minutes, the patient suffered extensive brain damage and eventually passed away. After the tragedy occurred, the hospital's handling of the incident only symbolically comforted the patient's family and stated that it was an "accidental incident" and did not conduct further investigation or rectification of the specific cause of the incident.
Another story is the crash of Flight 173, a famous "watershed" in the American aviation industry. What happened is roughly like this. On a sunny day with excellent flying conditions, a large passenger plane controlled by two experienced pilots and an excellent engineer was preparing to land at the Portland Airport. At that time, the landing gear down indicator light malfunctioned. The landing gear actually came down, but the indicator light did not come on. In order to eliminate possible accidents, the captain postponed the landing time and hovered over Portland while thinking of a solution. The captain was concentrating on thinking of a way to fix the landing gear. When the problem occurred, he did not notice the occurrence of another more serious problem, the fuel was gradually decreasing, and this serious problem was completely ignored by the captain who was meditating. The engineer reminded the captain several times, but because of his rank, He didn't dare to stop the captain's brooding behavior. Finally, tragedy occurred. The plane ran out of fuel and fell from the sky, killing eight passengers and two crew members.
The processes of the two stories are very similar. Both are simple mistakes made by experienced and skilled senior people. They did not neglect their duties, but ignored the occurrence of other problems because of their high concentration. . During the accident in the hospital, a nurse also discovered the problem, but because of his authoritative position as an expert, he did not dare to speak out to warn him, which was very similar to the engineer. However, the results of the two tragedy follow-up centers are completely opposite. Let's see how United handled the incident.
A few minutes after the plane crash, United Airlines set up a special investigation team, arrived at the accident scene the next day, carefully investigated the cause of the accident and collected evidence, and interviewed the surviving captain. . Then the root cause of the accident was carefully analyzed. The investigation lasted for nearly half a year. The investigation team issued an accident report, which not only explained the cause of the accident in detail, but also made suggestions for improvement. The contents of the report informed the aviation industry around the world, allowing all aviation industry personnel to access relevant files at that time. After this accident, the aviation industry invented the famous "crew resource management" (in short, it emphasizes teamwork and every member of the crew has the right to participate in crew management). This management method later saved thousands of lives. life.
The two have different ways of handling the incident afterwards. Based on the lessons learned from an accident, the aviation industry developed a set of management methods that later saved countless people. However, the medical industry is unwilling to face failure and uses words such as "accidental events" to avoid the facts. Moreover, this is not a case in a hospital in the United States, but a common phenomenon in the world's medical industry. The book lists some data showing that the daily death toll from medical accidents in the United Kingdom and the United States is equivalent to the crash of two Boeing 747 passenger planes. There is no example in the book. There are data from China, but looking at the medical incidents that are often reported in the news, I think this number may be different.
The book points out that evidence shows that the medical industry does avoid failure. We do not expect the medical industry and the aviation industry to take exactly the same actions to deal with accidents, because the risks in the medical industry are greater than those in the aviation industry, and there are risks in the aviation process. A variety of sophisticated instruments assist the driver, but doctors have to rely more on their own hands and experience to judge the handling of events during the operation. However, greater risks cannot be a reason to escape reality. Two hundred years ago, the medical industry made great progress by relying on clinical trial methods, because the majority of medical practitioners dared to face the failure of trials. But now, they cannot face the consequences of their small negligence during the operation. This will cause the medical industry to enter a "closed loop" again and stagnate.
Indeed, every doctor has gone through a long period of education and made extraordinary efforts. It is a bit harsh to ask them to bear the risk of failure for the advancement of the industry. However, missing the huge learning opportunities contained in failure is not only a regret for one person, but also a loss for the industry and even all mankind.
There is a famous saying in China, "Failure is the mother of success." However, there are too many people around us who have never stood up after failure. Is it because this famous saying is untrue? No, it's just that our "posture" when facing failure is incorrect. The huge amount of experience contained in a failure is far greater than the experience brought by a success. Failure is not terrible. What is really terrible is that the lessons from the past are not the guide for the future.
The book Black Box later introduced many cases of success brewing from failure. In the next few days, I will insist on sharing the insights I gained from this book every day. I also hope that everyone will correct me and criticize me, and learn from each other.